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IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


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1.1 


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2.0 


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Photographic 

Sciences 

Corporation 


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23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14380 

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CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  Canadian  de  microreproductions  historiques 


Technical  and  Bibliographic  Notas/Notaa  tachniquaa  at  bibliographiquas 


The  Institute  has  attempted  to  obtain  the  best 
original  copy  available  for  filming.  Features  of  this 
copy  which  may  be  bibliographically  unique, 
which  may  alter  any  of  the  images  in  the 
reproduction,  or  which  may  significantly  change 
the  usual  method  of  filming,  are  checked  below. 


0    Coloured  covers/ 
Couverture  de  couleur 


I     I    Covers  damaged/ 


D 


n 


Couverture  endommagAe 

Covers  restored  and/or  laminated/ 
Couverture  restaur^  et/ou  pelliculie 


I — I    Cover  title  missing/ 


Le  titre  de  couverture  manque 


□    Coloured  maps/ 
Cartes  giographiques  an  couleur 


D 


Coloured  ink  (i.e.  other  than  blue  or  black)/ 
Encre  de  couleur  (i.e.  autre  que  bleue  ou  noire) 


Coloured  plates  and/or  illustrations/ 
Planches  et/ou  illustrations  en  couleur 


Bound  with  other  material/ 
ReliA  avec  d'autres  documents 


Tight  binding  may  cause  shadows  or  distortion 
along  interior  margin/ 

La  re  liure  serrie  peut  causer  de  I'ombre  ou  de  la 
distorsion  le  long  de  la  marge  intiriaure 

Blank  leaves  added  during  restoration  may 
appear  within  the  text.  Whenever  possible,  these 
have  been  omitted  from  filming/ 
II  se  peut  que  certaines  pages  blanches  ajoutAes 
lors  d'une  restauration  apparaissent  dans  le  texte. 
mala,  lorsque  cela  Atait  possible,  ces  pages  n'ont 
pas  6ti  filmAes. 

Additional  comments:/ 
Commentaires  supplimentaires: 


L'Institut  a  microfilm*  le  meilleur  exemplaire 
qu'il  lui  a  M  possible  de  se  procurer.  Les  details 
de  cet  exemplaire  qui  sont  peut-4tre  uniques  du 
point  de  vue  bibliographique,  qui  peuvent  modifier 
une  image  reproduite.  ou  qui  peuvent  exiger  unc 
modification  dans  la  m^thode  normala  de  filmage 
sont  indiquis  ci-dessous. 


r~|   Coloured  pages/ 


D 


Pages  de  couleur 

Pages  damaged/ 
Pages  endommagies 

Pages  restored  and/oi 

Pages  restauries  et/ou  pelliculies 

Pages  discoloured,  stained  or  foxei 
Pages  dicolortes,  tachetAes  ou  piquies 


pn    Pages  damaged/ 

I — I    Pages  restored  and/or  laminated/ 

r~7|   Pages  discoloured,  stained  or  foxed/ 


□   Pages  detached/ 
Pages  ditachies 

EShowthrough/ 
Transparence 


Transparence 

Quality  of  prir 

Qualiti  inigale  de  I'impression 

Includes  supplementary  materii 
Comprend  du  materiel  supplAmentaire 

Only  edition  available/ 
Seule  Edition  disponible 


I      I    Quality  of  print  varies/ 

rn   Includes  supplementary  material/ 

rn    Only  edition  available/ 


Pages  wholly  or  partially  obscured  by  errata 
slips,  tissues,  etc..  have  been  refilmed  to 
ensure  the  best  possible  image/ 
Les  pages  totalement  ou  partieilement 
obscurcies  par  un  feuillet  d'errata.  une  pelure, 
etc.,  ont  M  filmies  A  nouveau  de  fapon  d 
obtenir  la  meilleure  image  possible. 


This  item  is  filmed  at  the  reduction  ratio  checked  below/ 

Ce  document  est  film*  au  taux  de  reduction  indiqui  ci-dessous. 


10X 

14X 

18X 

22X 

26X 

30X 

y 

12X 


16X 


20X 


24X 


28X 


32X 


Th«  copy  ftlm«d  h«r«  has  bMn  raproducad  thanka 
to  tha  ganaroaity  of: 

Medical  Library 
McQill  University 
Montreal 

Tha  imagaa  appaaring  hara  mrm  tha  baat  quality 
poaaibia  eonaidaring  tha  condition  and  iagibility 
of  tha  originai  copy  and  in  icaaping  with  tha 
filming  contract  apaclficationa. 


Original  oopiaa  in  printad  papar  covara  ara  fllmad 
baginning  with  tha  front  covar  and  anding  on 
tha  laat  paga  with  a  printad  or  illuatratad  impraa- 
sion,  or  tha  bacic  covar  whan  appropriata.  All 
othar  original  copiaa  ara  fllmad  baginning  on  tha 
f  irat  paga  with  a  printad  or  illuatratad  impraa- 
aion,  and  anding  on  tha  laat  paga  with  a  printad 
or  illuatratad  impraaaion. 


Tha  laat  racordad  frama  on  aach  mieroficha 
•hall  contain  tha  aymbol  ^»>  (moaning  "CON- 
TINUED"), or  tha  aymbol  y  (moaning  "END"), 
whichavar  appliaa. 

IMapa,  plataa,  charta,  ate.,  may  ba  fllmad  at 
diffarant  raductlon  ratioa.  Thoaa  too  iarga  to  ba 
antiraly  includad  in  ona  axpoaura  ara  fllmad 
baginning  in  tha  uppar  laft  hand  comar,  laft  to 
right  and  top  to  bottom,  aa  many  framaa  aa 
raquirad.  Tha  following  diagrama  iiluatrata  tha 
mathod: 


L'axamplaira  film*  fut  raprodult  grica  A  la 
ginAroait*  da: 

Medical  Library 
McGill  University 
Montreal 

Laa  imagaa  auhrantaa  ont  «t4  raproduitaa  avac  la 
plua  grand  aoin,  compta  tanu  da  la  condition  at 
da  la  nattatA  da  l'axamplaira  film*,  at  an 
conformity  avac  laa  condltiona  du  contrat  da 
fllmaga. 

Laa  axamplairaa  origlnaux  dont  la  couvartura  9n 
papiar  aat  imprimia  aont  filmia  an  commandant 
par  la  pramiar  plat  at  an  tarminant  aoit  par  la 
darnlAra  paga  qui  comporta  una  amprainta 
d'impraaaion  ou  d'illuatration,  aolt  par  la  aacond 
plat,  aalon  la  eaa.  Toua  laa  autraa  axamplairaa 
origlnaux  aont  fllmte  an  commandant  par  la 
pramlAra  paga  qui  comporta  una  amprainta 
d'impraaaion  ou  d'illuatration  at  •n  tarminant  par 
la  darnlAra  paga  qui  comporta  una  taila 
amprainta. 

Un  daa  aymbolaa  auivanta  apparattra  sur  la 
darnlAra  imaga  da  chaqua  mieroficha,  salon  la 
caa:  la  aymbola  — *>  signifia  "A  SUIVRE",  la 
aymbola  ▼  aignifia  "FIN". 

Laa  cartaa,  planchaa,  tablaaux,  ate,  pauvant  Atra 
fllmte  i  daa  taux  da  rMuction  diffAranta. 
Loraqua  la  document  aat  trap  grand  pour  Atra 
raprodult  an  un  aaul  cliche,  11  aat  film*  A  partir 
da  I'angia  aupAriaur  gaucha,  da  gaucha  h  droita, 
at  da  haut  an  baa,  an  pranant  la  nombra 
d'imagaa  nAcaaaaira.  Laa  diagrammaa  auivanta 
illuatrant  la  mAthoda. 


1 

2 

3 

1 

2 

3 

4 

5 

6 

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WITB  THX  OOMFUXEHTS  OF  THE  AUTHOB 


-A.  a-A.SE  OF 


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OF  THE  LEFT  FOOT 


wmf}  fissoQ5ipseD  liieofflp. 


BY 

A.  D.  BLACKADER,  M.D.,  M.R.C.S.,  Eng., 
Instnustor  in  Diseaaea  of  Children  in  MoOill  Uhivergity,  Montreal. 


\ 


Reprintkd  from  the  "Archives  op  Pediatrics,"  October,  1884. 


PHILADELPHIA 

JOHN  E.  POTTER  &  CO.,  Publishers, 

617  Sansom  Street. 

1884. 


-»fe#a.  ?>t,-«,^,.5tJI^^^^^ 


v-|W^^.«^S>»»it,«l 


ittiniaiX  fBfiLtmoKixnAm. 


A   CASE  OF  CONGENITAL   HYPERTROPHY  OF 
THE  LEFT  FOOT  WITH  ASSOCIATED  LIPOMA* 


BY  A.  D.  BLACKADER,  M.D.,  M.R.C.S.,  ENG. 
iTUtruetor  in  JHteattt  of  Children  in  McOiU  UnivertUy,  MojUreal. 

In  bringing  this  case  before  the  notice  of  the  association 
I  am  aware,  to  use  the  words  of  Curling  when  presenting  a 
Birailar  case  before  the  Medico-chirurgical  Society  of  Lon- 
don, that  such  facts  as  these  do  not  offer  the  same  interest 
as  do  others  more  frequently  met  with,  and  perhaps  more 
practical ;  still  they  should  be  deemed  worthy  of  record, 
and  may  become  of  much  interest  to  the  physiologist. 
Since  Curling  first  recorded  his  cases,  and  he  was  one  of 
the  earlier  ones  in  England  to  do  so,  other  cases  have  been 
recorded,  and  several  writers  have  called  attention  to  the 
many  curious  facts  in  connection  with  them.  One  of  the 
latest  is  Mr.  William  Anderson,  who  has  reported  a  case  in 
St.  Thomas  Hospital  Reports  for  1882,  and  along  with  his 
case  has  given  a  most  excellent  resum^  of  what  is  known 
on  the  subject.  To  his  paper  I  am  indebted  for  much 
which  I  now  lay  before  you. 

Among  the  earlier  cases  described  was  one  by  v.  Klein, 
of  hypertrophy  of  the  right  hand  of  a  boy,  in  which  the  four 
fingers  were  enlarged  and  associated  with  fatty  tumors. 
Wagner  about  the  same  time  mentions  the  case  of  a  girl  of 
sixteen  years  in  whom  the  second  toe  of  the  left  foot  was 
much  hypertrophied  and  the  plantar  surface  of  the  foot  cov- 
ered with  a  thick  layer  of  fat.  Reid  followed  in  England, 
and  then  Curling ;  and  since  then  numerous  contributions 

*  Bead  before  (he  Canada  Medical  AsBociation. 


Blackader  :  A  Case  of  Congenital  Hypertrophy. 

have  been  made  in  Germany,  England,  and  America. 
Of  a  few  of  the  more  interesting  cases  I  present  you  here 
with  sketches  and  short  notices. 

Anderson  defines  the  condition  as  follows:  A  gigantic 
growth,  probably  congenital  in  origin,  of  various  segments 
of  the  body,  exclusive  of  the  viscera.  It  is  almost  in- 
variably unilateral,  and  is  generally  limited  to  one  ex- 
tremity or  portion  of  an  extremity.  It  tends  to  implicate 
especially  the  bony,  ligamentous  and  integumentary  tis- 
sues, and  is  frequently  associated  with  lipomata  and  with 
angiectases,  and  angiomata  in  connection  with  the  circu- 
latory and  lymphatic  system.  It  does  not,  as  a  rule,  impair 
to  any  important  extent  the  functional  capacity  of  the 
part. 

With  regard  to  the  term  "congenital"  he  says, 
"  although  there  is  little  doubt  that  the  abnormality  has 
its  origin  in  foetal  life,  as  yet  direct  evidence  of  its  exist- 
ence at  birth  has  seldom  been  adduced.  In  only  three 
Cfises,  Owen,  Higginbottom,  and  Friedberg,  has  it  been 
averred  that  the  deformity  was  seen  immediately  after 
birth  of  the  child.  In  one  case  an  operation  seems  to 
have  been  the  exciting  cause. 

To  the  term  "hypertrophy"  Anderson  also  objects, 
stating  that  although  in  a  few  cases  the  general  characters 
of  true  hypertrophies  are  present,  in  most  their  histolog- 
ical character  and  associations  should  delegate  them  to  a 
lower  pathological  status  than  that  occupied  by  the  true 
hypertrophies. 

Of  the  etiology  little  is  known.  It  does  not  appear  to 
be  hereditary.  There  was  certainly  no  such  history  in 
my  own  cases  for  several  generations  back.  Mental  im- 
pressions on  the  mother  during  gestation  are  quoted. 
In  Anderson's  case  the  mother  referred  the  deformity  to 
the  fact  that  she  had  been  trodden  on  by  a  cow  while 
carrying  the  child.  In  m}'  own  case  the  mother  is  firm 
in  the  belief  that  the  whole  trouble  is  owing  to  a  some- 
what prolonged  fright  about  the  tenth  week  of  her  preg- 
nancy. She  was  out  driving  with  her  family  in  an  open 
wagon,  with  her  left  foot,  for  want  of  room,  hanging  out- 


.»■ 


Blackader  :  A  Case  of  Congenital  Hypertrophy. 

side.  The  road  was  narrow,  and  a  carelessly  driven 
heavy  cart  came  up  from  behind  and  was  driven  along- 
side them  for  some  distance.  She  said  ahe  expected  every 
moment  her  foot  would  be  crushed.  While  these  impres- 
sions may  be  mere  coincidences,  until  we  can  prove  thein 
so,  it  were  better  that  facts  of  this  kind  should  be  noted. 

The  extent  of  the  part  hypertrophied  varies  from  a 
single  digit  to  the  entire  half  of  the  body.  The  hyper- 
trophy always  increases  towards  the  distal  end,  thus  the 
phalanges  will  be  more  hypertrophied  than  the  metatarsal 
or  -carpal  bones,  and  they  more  in  proportion  than  the 
bones  of  the  fore-arm  or  leg.  The  hypertrophy,  however, 
seldom  includes  the  whole  of  the  digits.  The  localiza- 
tion of  the  afiection  does  not  appear  to  be  related  to  any 
special  vascular  or  nervous  territories.  Its  course  is  gen- 
erally progressive;  sometimes,  for  a  time,  the  growth 
appears  uniform  with  the  rest  of  the  body,  but  generally 
sooner  or  later  the  hypertrophy  becomes  more  marked, 
and  its  nutrition  evidently  excessive.  The  rate  of  increase 
may  vary  from  time  to  time ;  periods  of  slow  develop- 
ment, or  even  apparent  arrest,  may  be  followed  by  new 
and  rapid  growth.  In  most  cases  the  process  does  not 
extend  beyond  the  seat  of  the  original  hypertrophy,  but 
in  a  few  we  notice  extension  towards  the  trunk.  As  a 
rule,  the  growth  goes  on  without  pain,  inflammation,  or 
much  interference  with  function. 

As  to  the  classification  of  these  cases,  Ande»". on  sets 
aside  as  unsatisfactory,  and  I  think  justly,  that  of  v. 
Fischer,  which  is  founded  in  great  part  on  the  extent  of 
the  hypertrophy,  and  prefers  the  division  into  true  and 
false.  The  first  class  forms  a  very  small  one,  yet  there 
are  a  few  cases  sufficiently  well-marked  where  all  the 
structures  of  one  side  are  hypertrophied,  the  vascular 
supply  on  that  side  enlarged,  the  temperature  elevated, 
and  the  power  of  the  limb  increased.  Into  the  other 
division  is  placed  all  those  where  the  size  of  the  part  is 
augmented  by  an  unequally  distributed  hyperplasia  of 
the  skeleton  and  soft  parts.  This  forms  by  far  the  larger 
division.    In  these  the  arterial  supply  is  proportionate 


Blackader  :  A  Case  of  Congenital  Hypertrophy. 

only  to  the  normal  size  of  the  part,  and  the  functional 
capacity  is  somewhat  deteriorated.  These  cases  for  prac- 
tical purposes  he  divides  into  two  groups : 

1.  No  deformity — parts  being  symmetrical. 

2.  Deformity.    Arising  from 

a.  Excess  of  adipose  tissue  or  vascular  tissues. 

6.  Articular  distortion. 

c.  Associated  defects  of  development,  c.^r.  syndactyly. 
With  regard  to  the  several  tissues  of  the  hypertrophied 
part  we  notice  that  the  bones  are  always  enlarged,  but 
principally  in  their  extremities.  The  cartilages  and  liga- 
luents  of  the  joints  and  the  tendons,  are  usually  thickened. 
The  muscles,  themselves,  the  arteries,  and  the  nerves  are 
seldom  increased  in  size. 

The  pathology,  like  the  etiology,  is  very  obscure. 
Friedberg  suggested  some  affections  of  the  vaso-motor 
nerves,  or  some  impediment  in  the  circulation  of  a  lymph 
vessel  during  intra-uterine  life.  A  primitive  vice  of  the 
middle  lamina  of  the  blastodermic  membrane  is  opposed 
by  the  fact  that  che  walls  of  the  trunk,  which  are  directly 
formed  from  the  middle  lamina,  are  comparatively  sel- 
dom implicated.  The  theory  of  partial  intra-uterine 
strangulation  fails  to  explain  cases  where  half  the  body 
is  effected.  We  were  surprised  that  Mr.  Anderson  makes 
no  reference  to  the  writings  of  Dr.  S.  C.  Busey,  of  Wash- 
ington, who  has  carefully  studied  these  growths  in  con- 
nection with  a  case  of  congenital  lymph-angiectasis, 
which  came  under  his  observation.  In  a  most  exhaustive 
article  published  some  years  ago  in  the  American  Journal 
of  Obstetrics  he  thus  suras  up :  These  considerations  lead 
me  to  the  conclusion  that  thelipomatousandfibromatous 
degenerations  exhibited  in  the  foregoing  cases  of  giant 
growth  are  the  pathological  results  of  a  stagnation  of 
lymph.  This  stasis  may  be  occasioned  by  conditions 
which  affect  the  lymph  channels,  or  which  primarily  in- 
volve the  circulatory  apparatus  causing  excessive  transu- 
dation of  blood-serum,  or  both  systems  may  be  concerned 
either  proximately  or  remotely.  In  the  lipomatous  form 
of  degeneration  the  altered  nutrition  is  due  principally 


, 


'   Blackader  :  A  Case  of  Congenital  Hypertrophy. 

to  some  defect  of  the  lymph  apparatus  producing  lymph 
stasis,  while  connective  tissue  hyperplasia  is  due  to  aug* 
mented  venous  supply. 

And  again,  it  cannot,  however,  be  denied  that  inflam- 
matory processes,  either  erpsipelatous  or  elcphantoid,  do 
constitute  the  beginning  of  many  of  the  cases  of  hyper- 
trophic development,  which  are  characterized  by  all  the 
phenomena  which  I  have  ascribed  to  occlusion  and  dilata- 
tion of  lymph  channels,  and  consequent  stasis  of  lymph. 
But  this  fact  does  not  antagonize  my  view,  for  it  is  ad- 
mitted that  such  changes  as  result  from  the  inflammatory 
processes  necessarily  cause  lymph-angiectasis,  and  the 
argument  relates  to  the  effects,  not  the  causes  of  the  stasis 
of  lymph.  I  have  previously  referred  to  the  suggestion 
that  the  congenital  cases  of  ectasia,  stenosis,  and  oblitera- 
tion of  lymph  channels,  may  have  been  caused  by  inflam- 
matory conditions  taking  place  during  intra-uterine  life, 
and  am  willing  to  accept  this  hypothesis  as  a  probable 
explanation,  but  the  numerous  cases  of  congenital  defect 
of  formation  of  portions  of  the  lymphatic  system,  accom- 
panied by  hypertrophic  enlargements,  will  not  admit  of 
its  universal  application.  The  one  essential  condition  is 
interruption  to  the  current  and  detention  of  the  lymph, 
it  matters  not  whether  it  be  caused  by  devastated  glands, 
absence  of  valves,  absence  of  anastomotic  connection 
between  the  superficial  and  deep-seated  system  of  vessels, 
or  other  congenital  or  acquired  conditions. 

The  following  is  the  history  of  my  case : 

In  March  of  last  year,  Mrs.  W.,  aged  thirty-four  years, 
was  confined  by  me  of  her  fourth  child.  The  confinement 
was  in  every  respect  a  normal  one,  and  her  recovery  good. 
The  child  was  a  strong,  healthy  one,  of  more  than  aver- 
age weight,  well-formed  in  every  respect  excepting  the 
peculiar  formation  of  the  left  foot,  which  was  noticed  the 
night  of  the  birth,  and  more  carefully  examined  the  fol- 
lowing morning.  The  following  are  my  notes  about  that 
time :  Both  legs  and  thighs  apparently  the  same,  and  well 
developed ;  no  distinguishable  difference  in  size,  firmness 
nor  appearance ;  no  marks  on  skin ;  posterior  half  of  foot 


Blackader:  A  Ckse  of  Congenital  Hypertrophy.  ( 

scarcely  if  at  all  enlarged,  but  anterior  half  enlarged  in 
all  its  diameters,  and  presents  on  its  plantar  surface  a 
large,  firm,  yet  somewhat  elastic  tumor  of  smooth,  rounded 
surface,  extending  whole  breadth  of  foot,  and  from  mid- 
dle of  foot  to  root  of  toes  •,  the  second  and  third  toes  are 
webbed,  much  larger  than  the  great  toe,  and  project  a 
full  half  inch  beyond  it ;  the  fourth  and  fifth  toes  are 
both  enlarged,  but  to  a  much  less  extent;  the  skin  is 
perfectly  normal  in  appearance;  the  movement  of  the 
toes  is  considerably  interfered  with,  apparently  by  the 
tumor;  there  is  no  perceptible  tenderness  over  the  en- 
largement, and  no  increase  of  temperature  above  its  fel- 
low. 

Dr.  Itoddick  was  called  in  consultation,  and  it  was 
decided  that  there  should  be  no  immediate  interference. 

About  six  months  afterwards,  the  mother  again  brought 
the  child  to  me,  saying  that  the  foot  was  rapidly  increas- 
ing in  size — growing,  she  thought,  faster  than  the  other. 
I  now  determined  on  using  continuous  pressure  by  means 
of  a  Martin's  bandage,  and  obtained  one  2J  inches  broad  ; 
had  numerous  holes  punched  in  it,  and  then  slit  it  up 
lengthwise  through  the  middle  for  about  two  yards,  that 
I  might  apply  it  more  evenly.  Very  gentle  pressure  was 
made,  but  after  a  few  night's  use  of  it  the  mother  got  dis- 
couraged, as  it  caused  the  child  much  irritation,  and  has 
made  it  very  restless  and  wakeful. 

After  this  I  did  not  see  it  again  until  the  beginning  of 
the  year,  when  I  again  saw  it,  and  as  Dr.  Roddick  was 
out  of  town,  called  in  Dr.  Fenwick  in  consultation.  He 
strongly  advised  me  to  persevere  with  the  pressure  for 
the  present.  This  was  now  with  great  care  kept  almost 
constantly  applied  for  nearly  two  months.  Twice  a  day 
the  skin  was  sponged  with  spirits  of  wine,  well  dusted 
with  starch  powder,  and  the  bandage  reapplied.  Till  I 
was  confident  that  they  could  apply  it  well  I  called  every 
day,  and  either  applied  it  myself  or  saw  it  done.  The 
results  were  not  very  encouraging  to  the  mother,  although 
I  convinced  myself  it  had  some  slight  effect  in  retarding 
the  growth,  as  the  measurements,  which  were  very  care- 
fully taken,  will  show. 


Blackader  :  A  Case  of  Covgaiital  Hypertrophy, 

An  operation  was  now  decided  on.  The  child  was 
about,  fourteen  months  old  imd  in  j)erfoct  health.  To 
flecure  a  good  room,  quietness  and  skilled  nursing,  it  was 
taken  to  a  private  hospital,  where,  with  the  assistance  of 
Dr.  James  Bell,  and  myself,  Dr.  Roddick  performed  the 
operation.  Jusl;  before  the  operation,  while  the  child  was 
under  ether,  the  following  ni>tcs  and  measurements  were 
taken :  Heel  enlarged  ;  about  centre  of  plantar  surface  a 


CoNCBNITAL  HYPERTROPHY. 


tumor-like  mass,  extending  to  base  of  big  and  little  toe, 
and  forward  to  terminal  phalanx  of  second  and  third 
toes,  which  latter  are  webbed  and  much  hypertrophied, 
and  project  beyond  the  large  toe  three-quarters  of  an  inch, 
as  if  carried  forward ;  third  toe  also  much  enlarged,  but 
considerably  shorter  than  the  two  previous;  great  toe 
scarcely  at  all  enlarged,  but  small  toe  two  or  three  times 
the  size  of  opposite ;  the  dorsum  of  the  foot  also  consider- 
ably thickened ;  no  apparent  enlargement  of  either  the 


Blackader  :  A  Case  of  Congenital  Hypertrophy. 

posterior  tibial  or  anterior  dorsal  arteries ;  no  alteration 
of  the  skin  over  the  whole  leg  noticeable,  and  no  appar- 
ent alteration  in  the  lymphatic  or  venous  system;  no 
nevus  to  be  seen  on  any  part  of  the  body. 

The  operation  was  commenced  by  an  incision  commenc- 
ing on  tue  under  surface  at  junction  of  ^eat  and  second 
toes,  and  extending  backwards  to  centre  of  foot  at  poster- 
ior edge  of  tumor,  where  it  was  joined  by  another  similar 
incision  from  the  junction  of  third  and  fourth  toes;  sim- 
ilar incisions  were  made  on  the  dorsal  surface,  and  the 
whole  of  the  second  and  third  toes,  with  anterior  two- 
thirds  of  the  metatarsal  bones,  were  removed.  Finding 
that  the  third  metatarsal  bone  was  also  hypertrophied, 
that  toe,  with  the  anterior  portion  of  its  metatarsal  bone, 
was  removed,  and  as  much  of  the  tumor-tissue,  which 
was  now  seen  to  be  a  diffuse  lipoma,  was  removed,  and 
the  edges  brought  together.  The  whole  operation  was 
done  under  strict  antiseptic  precautions.  The  tempera- 
ture never  rose  over  99J°,  the  parts  seemed  to  unite  by 
first  intention,  there  was  scarcely  any  discharge,  and  by 
the  tenth  day  most  of  the  stitches  were  taken  out. 

After  the  operation  I  asked  Dr.  Wilkins,  as  a  pathologist, 
to  examine  the  tumor,  which  he  pronounced  to  be 
principally  fatty,  but  to  contain  numerous  bands  of 
fibrous  tissue.  Dr.  William  Sutherland,  Assistant  De- 
monstrator of  Anatomy  in  McGill  University,  kindly 
examined  the  amputated  toes,  and  reported :  Phalanges 
enlarged  but  principally  at  their  articular  extremities, 
which  were  much  increased  in  size ;  cartilages  apparently 
thickened ;  tendons  hypertrophied  at  their  insertion. 

As  to  the  full  results  from  this  operation,  a  much 
longer  time  must  be  allowed  to  elapse  before  we  can  make 
any  assertions.  It  will  be  sufficient  for  the  present  to 
say  that  the  child  can  now  walk  well.  A  slight  tendency 
to  talipes  varus  is  developing ;  but  we  think  that  can  be 
easily  overcome ;  and  the  foot,  though  still  somewhat 
larger  than  its  fellow,  can  be  accommodated  in  a  shoe  of 
ordinary  size,  and  thus  presents  no  deformity : 


Adams:  Strabismus  Coiivei-gem. 

MEASUREMENTS.        » 

Normal/ool.  Hvpertrophied  foot. 

T^r.„fl,  f     X.    -.                             January.       May.  January.  May. 

Length  (inches) 4             4^  g^  ^  "'"y- 

Circumference  around  ball  of  foot..4J            5  7^  7! 

Circumf.  around  heel  and  ankle... 6             64  6i  fif 

Circumference  around  calf. 7              7^  71  -f 

Circumference  around  thigh 9             9^  gj  nf 


•./ 


4 


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.; 


<h* 


<•< 


THE 


THE  ONLT  JOURNAL  IN  THE  ENGLISH  LANOUAOE 

DEVOTED  TO  THE 

Diseases  of  Infants  and  Children. 


EDITED   BY 


WILLIAM  PERRY  WATSON,  A.M.,  M.D., 

Assistant  to  the  Chair  of  Diseases  of  Children  in  the  New  York 

Polyclinic. 

dOHN  E.  POTTER  &  CO.,  Publishers. 

617  Sansom  street,  PHILADELPHIA 


•  y 


■^g: 


